SEC Form 4 · accession 0001209191-17-014104
IMPINJ INC · PI
Statement of changes in beneficial ownership, as filed. Original on EDGAR ↗
Reporting owner
Tom A Alberg
Director
Period of report
Feb 22, 2017
Accepted (ET)
Feb 23, 2017 · 9:32 pm EST
Rule 10b5-1 plan
unknown — predates the checkbox
Issuer CIK
0001114995
Table I — non-derivative securities
| Security | Date | Code | Shares | Price | A/D | Owned after | D/I | Nature of ownership |
|---|---|---|---|---|---|---|---|---|
| Common StockF2,F3 | Feb 22, 2017 | J | 969,886 | $0.00 | D | 235,551 | I | See footnote |
| Common StockF5,F3 | Feb 22, 2017 | J | 105,649 | $0.00 | D | 129,902 | I | See footnote |
| Common StockF3 | Feb 22, 2017 | J | 129,902 | $0.00 | D | 0 | I | See footnote |
| Common Stock | Feb 22, 2017 | J | 42,151 | $0.00 | A | 77,865 | D | |
| Common Stock | Feb 22, 2017 | J | 31,489 | $0.00 | A | 109,354 | D | |
| Common Stock | Feb 22, 2017 | J | 1,415 | $0.00 | A | 110,769 | D | |
| Common StockF8 | Feb 22, 2017 | J | 4,817 | $0.00 | A | 4,817 | I | By Alberg Family Investments LLC |
| Common StockF9 | Feb 22, 2017 | J | 31,219 | $0.00 | A | 31,219 | I | By Raven Trust Fund |
Table II — derivative securities
No Table II lines on this filing.
Explanation of responses
- F1Pro rata distribution from Madrona Venture Fund I-A, LP, of which the reporting person is a managing member.
- F2129,902 of these shares are held by Madrona Managing Director Fund, LLC and 105,649 of these shares are held of record by Madrona Venture Fund I-B, L.P.
- F3Madrona Investment Partners, LLC, as the sole general partner of Madrona Venture Fund I-A, L.P. and Madrona Venture Fund I-B, L.P., may be deemed to beneficially own certain of the shares held of record by Madrona Venture Fund I-A, L.P. and Madrona Venture Fund I-B, L.P. but disclaims beneficial ownership of such shares in which it does not have an actual pecuniary interest. Tom A. Alberg, a member of the board of directors, disclaims beneficial ownership of all shares held of record by Madrona Managing Director Fund, LLC, Madrona Venture Fund I-A, L.P. and Madrona Venture Fund I-B, L.P., in which he does not have an actual pecuniary interest. By virtue of their relationship as affiliated entities who have overlapping general partners and managing directors, Madrona Managing Director Fund, LLC, Madrona Venture Fund I-A, L.P., Madrona Venture Fund I-B, L.P., Madrona Investment Partners, LLC and Mr. Alberg may be deemed to share voting and investment control of the record shares.
- F4Pro rata distribution from Madrona Venture Fund I-B, L.P., of which the reporting person is a managing member.
- F5Represents 129,902 shares held by Madrona Managing Director Fund, LLC.
- F6Pro rata distribution from Madrona Managing Director Fund, LLC, of which the reporting person is a managing member.
- F7Pro rata distribution from Madrona Investment Partners, LLC, of which the reporting person is a managing member.
- F8Shares held of record by the Alberg Family Investments LLC. Mr. Alberg shares voting and dispositive control over such shares but disclaims beneficial ownership over such shares.
- F9Shares held of record by Raven Trust Fund. Mr. Alberg shares voting and dispositive control over such shares but disclaims beneficial ownership over such shares.